Kelly P. Schultz

Presentation of a Rare Lobulated Tongue Anomaly

The presence of a bilobed tongue is a rare congenital malformation. There are multiple reports of a bifid anterior lobe; however, a case with complete separation of isolated anterior and posterior lobes has not been previously described. We report the case of a 2-year-old male, who presented with a V-shaped mandible and glossoptosis in the setting of respiratory distress and difficulty feeding, incidentally found to have a bilobed tongue with independent anterior and posterior lobes.

Medical Consultation Experience Questionnaire: Assessing perceived alliance and experienced confusion during medical consultations.

The Medical Consultation Experience Questionnaire (MCEQ) is a new, brief self-report instrument that can be used with both adult patients and parents of child patients to assess two dimensions of people’s experiences interacting with medical practitioners: Alliance and Confusion. In contrast with existing measures, the MCEQ was expected to provide good discrimination across a full range of experience levels and to assess two distinct dimensions of experience with good factor validity. It was developed in a series of 7 preliminary studies (with 758 participants) and tested in 3 subsequent validation studies, which are the focus of the present report. Study 1 was an Internet sample of 199 parents of child patients, Study 2 was a hospital sample of 173 parents of child surgery patients, and Study 3 was an Internet sample of 204 adult patients. A confirmatory factor analysis specifying strict measurement invariance across the 3 groups produced a good fit. An item response theory analysis suggested that scales on the MCEQ provide good discrimination across a wide range of experience levels. The new scales measuring Alliance and Confusion each had a distinct pattern of convergent validity associations with criterion variables regarding alternate measures of consultation experience, treatment context, and patient-reported perception, behavior, and affect. Results support the validity of the MCEQ and suggest that Alliance and Confusion are two distinct and informative dimensions of medical consultation experience.

Newborn Ear Deformities: Early Recognition and Novel Nonoperative Techniques

Congenital auricular anomalies are common sources of aesthetic concern and psychosocial distress for both children and their parents. Only one-third of these anomalies self-correct, leaving a large need for acceptable corrective methods. Otoplasty is often the standard treatment; however, newer nonsurgical methods, including splinting and molding in the neonatal period, have shown favorable results without the complications of surgical intervention and with the advantage of early intervention. These treatment options have not yet been widely adopted in Western countries due to delayed diagnosis of auricular deformities and confusion regarding treatment indications and technique.

Frontal Sinus Fractures

Abstract The frontal bone serves a protective role, representing the transition between the facial skeleton and the cranium. Within its enclosure, the frontal sinus lies adjacent to many important intracranial structures, and injury to this region has severe complications if not properly managed. Historically, the goals of frontal sinus fracture management have been to best prevent intracranial complications with invasive procedures, but a recent shift favoring conservative management now aims to preserve the form and function of the frontal sinus and its outflow tract. With the advancement of endoscopic techniques and the development of new technologies, many alternatives to aggressive surgical management are available.

Review of “Repealing the ACA Without a Replacement—The Risks to American Health Care” by Obama BH in N Engl J Med 376: 297-299, 2017

negligence of global surgery by ‘‘embedding surgery within the global health agenda, catalyzing political change, and defining scalable solutions for provisions of quality surgical and anesthesia care for all.’’ Frilling adds that this mission can be carried forward on an institutional level by partnering with programs in lowand middle-income countries to provide local training, infrastructure development, research assistance, and outcomes tracking. Furthermore, global surgery should be added to the curricula of training programs and professional societies. The developed world is plagued by its own troubles. An unfortunate reality facing these countries is the increasing death and destruction wrought by terrorist attacks. Analysis of the multiple attacks in Western Europe has shown that cooperation, professionalism, and incorporation of disaster training into medical school curriculum are vital to responding to disasters appropriately. Furthermore, more medical personnel will need training in scene triage, control centers, recognition of ‘‘war-type injuries,’’ synchronization of emergency services, and dealing with post-traumatic stress disorder. Frilling’s insightful synthesis of both global and local problems creates a framework for current and future surgeons to address the changing global landscape. Surgery will no longer be a neglected stepchild of global health but will take its rightful place as an indispensable part of health care.

Review of “Patient Blood Management: Success and Potential in the Future” by Spahn DR in Ann Surg 264:212–213, 2016

P atient blood management (PBM) is a multidisciplinary approach to the improvement of patient safety and surgical outcomes by treatment of preoperative anemia, minimization of perioperative blood loss, and reduced need for allogenic RBC transfusions. In a study by Meybohm et al, PBM was implemented in 4 German University Hospitals across all surgical disciplines and patient safety was assessed as a composite metric of in-hospital mortality, myocardial infarction, ischemic stroke, acute renal failure, pneumonia, and sepsis. The study found that PBM improved patient safety, reducing RBC transfusions by 17% and reducing acute renal failure by 30%. Favorable results correlated with the length of time PBM had been a part of the hospital’s standard practice. It is important to note that such an integrative program would not be expected to reach its full potential within 1 or 2 years of implementation, and, therefore, measured safety benefits of PBM can be expected to continually increase with time. Many centers involved in the study were unable to fully effect PBM standards, particularly in treatment of preoperative anemia. Spahn cites this as an important direction of future research, as preoperative anemia is a proven risk for perioperative mortality, acute kidney injury, infection, need for RBC transfusion, and prolonged hospital stay. Effective treatment of preoperative anemia will require clinicians to familiarize themselves with standard definitions of anemia, recognize the risk of seemingly mild patients of anemia, and report patients with sufficient time for treatment, and will require hospitals to invest in protocol for treatment programs and ‘‘intelligent scheduling systems.’’ Financial burden is perhaps the largest barrier to introduction of PBM and of concern to both physicians and administrators. This study fails to address the cost of implementation, but previous researchers have concluded that PBM measures are effective in saving costs over time. The benefits of PBM are proven and future attention to treatment of preoperative anemia and logistics of implementation will allow PBM programs to further reduce the need for RBC transfusions and improve patient safety.

Secondary Repair of Posttraumatic Enophthalmos and Extraocular Movement Disorders

Abstract Enophthalmos, or recession of the eye posteriorly and inferiorly, is a potential sequela of orbital trauma and a source of significant cosmetic and functional concern. Late enophthalmos occurs when early reconstruction of the bony orbit fails to completely restore normal orbital shape and volume, resulting in aesthetic deformity and persistent diplopia. In this article, we provide a framework for evaluation of posttraumatic enophthalmos and outline the surgical principles of secondary repair necessary to optimize globe position. With implementation of proper craniofacial exposure, osteotomy, and orbital reconstruction, surgeons may achieve significant improvement in both the aesthetic and functional sequelae of enophthalmos.